Consider cataract effects before prescribing alpha blockers - - Modern... 1 of 4 ModernMedicine http://www.modernmedicine.com/modernmedicine/clinical+insights/Co... Welcome back, Dr. Chang ModernMedicine Community Edit Your Profile / Log Out Enter your keyword ModernMedi c i ne Home Clinical Perspectives Business Perspectives Patient Care Learning Rec ommended Medic al Si tes Community Products Careers About Us HOT TOPICS: Cardiometabolic Disorders & Weight Liability & Risk Management Health Care IT E-mail Alerts RSS Feeds Consider cataract effects before prescribing alpha blockers Publish date: Aug 11, 2008 By: Lois A. Bowers Email | Print | Share | Save | License Before prescribing alpha blocker treatment, a primary care physician (PCP) should consider involving the cataract surgeon when treating a patient with a known diagnosis of cataract. So says an "educational update statement" that the American Society of Cataract and Refractive Surgery (ASCRS) and the American Academy of Ophthalmology (AAO) have issued in partnership with the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) in an effort to further educate PCPs about the connection between alpha blockers, Dr. Chang Dr. Oetting such as tamsulosin (Flomax, Boehringer Ingelheim Pharamceuticals), and intraoperative floppy iris syndrome (IFIS) during cataract surgery. Practice Tools PCPs write most of the prescriptions for alpha blocker treatment for the symptoms of benign prostatic hyperplasia (BPH) in men, said David F. Chang, MD, chairman of the ASCRS Cataract Clinical Committee (urologists, he said, often do not see such patients until medical therapy has failed). The drugs, however, have been linked to IFIS, which manifests itself as poor pupil dilation before cataract surgery, billowing and prolapse of the iris, and progressive miosis during the surgery. CODING COUNSELOR Simple and accurate ICD-9 code search. START HERE POPULAR ARTICLES Dr. Chang and John R. Campbell, MD, published the first paper about the association between IFIS and the systemic alpha-1 adrenergic antagonist tamsulosin in the literature (J Cataract Refract Surg. 2005;31:664-673). Tamsulosin is the most commonly prescribed medication for BPH treatment, according to the ASCRS Cataract Clinical Committee. The drug is selective for the alpha-1A receptor subtype, which is predominant in the prostate and also in the iris dilator smooth muscle. As part of the initiative, the ACP and AAFP recently posted the educational statement on their respective Web sites. In part, the statement says: "In a patient with a known diagnosis of cataract, prescribing physicians may wish to consider involving the patient's cataract surgeon prior to initiating nonemergent, chronic tamsulosin or alpha blocker treatment. Options might include an eye exam or having either the patient or the prescribing MD communicate with the cataract surgeon. Patients should also be encouraged to report any prior or current history of alpha-1 antagonist use to their ophthalmic surgeon prior to undergoing any eye surgery." Weight-based dosing: Extended-release minocycline efficient, predictable FDA warns Allergan on Aczone promotion Exit Accutane: Derms' reactions mixed as Roche pulls long-standing remedy Gaining control: Birth control pills, spironolactone first-line treatments for hormonal acne Getting to the root: Look below the surface for cause of hyperandrogenetic symptoms MORE POPULAR ARTICLES Featured Jobs That last point aims to address the potential concerns of patients who already are taking alpha blockers, according to Dr. Chang, also clinical professor of ophthalmology, University of California, San Francisco. "It is important to reassure these patients that the prognosis of cataract surgery remains excellent, as long as the eye surgeon is forewarned about their medication history," he said. More Jobs The statement also points out that IFIS still can occur even after patients have discontinued tamsulosin therapy for more than a year, however. "We are trying to explain that it isn't the case that we simply can stop the drug to avoid IFIS altogether," Dr. Chang said. IFIS survey The statement was prompted by a recent survey undertaken by the ASCRS Cataract Clinical Committee. A link to the online survey, which consisted of 26 multiple-choice questions, was sent to 6,000 ASCRS members in March; 957 members responded, 75% of whom said they were from the United States. Results were published in the July issue of the Journal of Cataract and Refractive Surgery (2008;34:1201-1209). SPONSORED MEDIA OTLA Video Player Multimedia: Why Patients Considering an IUC May Say YES to ParaGard sponsored multimediaPromiseb A non steroidal topical cream for managing seborrheic dermatitis MORE MEDIA 03.12.2009 14:23 Consider cataract effects before prescribing alpha blockers - - Modern... 2 of 4 http://www.modernmedicine.com/modernmedicine/clinical+insights/Co... Ninety-five percent of respondents said that tamsulosin use by patients makes cataract surgery more difficult, and 77% reported a belief that surgical risk is increased in patients with a known history of taking the drug. Approximately 52% of respondents reported experiencing significant iris damage that was higher in patients with IFIS than in patients without IFIS during the 2 years preceding the survey, and 24% said that the rate of posterior capsule rupture they saw in patients with IFIS was higher than the rate in non-IFIS patients during the 2 years preceding the survey. When asked whether IFIS is more likely to occur with tamsulosin or with a non-selective alpha-1 blocker, 21% of survey respondents said that they did not have enough experience to answer the question. Of those with an opinion, however, more than 90% expressed a belief that IFIS is more likely to occur with tamsulosin than with a non-selective alpha-1 blocker. IFIS also has been associated with non-selective alpha-1 blockers such as alfuzosin HCl (Uroxatral, SanofiAventis), doxazosin mesylate (Cardura, Pfizer), and terazosin HCl (Hytrin, Abbott Laboratories), but several prospective and retrospective studies suggest that the complication is more likely to occur with tamsulosin than with non-selective alpha blockers, according to the ASCRS Cataract Clinical Committee. Another survey question asked ophthalmologists whether they would take tamsulosin if they had BPH and mildly symptomatic cataracts. Twenty-three percent of respondents said they would avoid all alpha blockers if possible, 23% said they would undergo cataract surgery first, and 17% said they would take a non-selective alpha blocker instead of tamsulosin. No treatment recommendations The educational update statement does not make any recommendations regarding medical or surgical treatment of BPH or cataract, Dr. Chang stressed. "A survey is not a scientific study and can have all sorts of biases. It does provide valuable insight into the clinical issues currently facing cataract surgeons and their patients taking these drugs, however," he said. "We're not at all trying to make recommendations relating to timing of cataract surgery or to what should be prescribed for BPH or hypertension," Dr. Chang continued. "We're simply trying to call attention to the kinds of problems that ophthalmologists are encountering with IFIS and to suggest that the cataract surgeon can be an excellent resource in terms of educating the patient as well as the PCP." Both Dr. Chang and Thomas A. Oetting, MD, chairman of the cataract/anterior segment section of the AAO Practicing Ophthalmologists Curriculum panel, said that part of the statement regarding the relatively higher risk of IFIS with tamsulosin compared with non-selective alpha blockers might be viewed as the most controversial. "We don't have sufficient evidence to advocate one alpha blocker over another, and we certainly are not saying that tamsulosin, which is a good drug, should be avoided," Dr. Chang said. "But for patients with cataracts, their cataract surgeon is probably in the best position to assess the risk of starting therapy with an alpha blocker such as tamsulosin." Ophthalmologists have varying opinions about how difficult alpha blockers can make cataract surgery, he said, adding that other co-morbidities, including pseudoexfoliation or a brunescent nucleus, enter into the treatment decision. Other options Echoing the research cited in the educational statement, however, and noting the results of the ASCRS survey, Dr. Oetting, also professor of clinical ophthalmology, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, said, "The one agent, tamsulosin . . . seems to be a little bit more likely to cause the syndrome, and so maybe if all other things were equal, [a physician] could consider trying one of the other agents." New information about the 5-alpha reductase inhibitor finasteride, part of a different drug class for the treatment of BPH, seems encouraging, Dr. Chang said. In May, an analysis was released regarding a large randomized, prospective trial that followed more than 18,000 male patients aged more than 55 years. This new information strengthened the conclusion that finasteride, a generic drug, can reduce the risk of developing prostate cancer by approximately 30%, he said. "There clearly are many factors to weigh when prescribing any drug," Dr. Chang said. "In light of this new information, however, I personally would try finasteride as a first-line treatment if I had a cataract and early BPH symptoms." What happens next? With the release of the educational statement and survey results, PCPs now will have additional information and literature references to consult about the alpha blocker/IFIS relationship, Dr. Chang said. Beyond that, he said, ASCRS and AAO leaders hope that the effort will facilitate more discussions between ophthalmologists and PCPs, PCPs and patients, and 03.12.2009 14:23 Consider cataract effects before prescribing alpha blockers - - Modern... 3 of 4 http://www.modernmedicine.com/modernmedicine/clinical+insights/Co... ophthalmologists and patients. The desired end result of the survey and initiative is improved patient safety for cataract surgery, a goal about which both ophthalmologists and PCPs can agree, Dr. Chang said. "Those of us within ASCRS and AAO who worked on this educational update statement were quite concerned about not wanting to burden PCPs arbitrarily or unnecessarily, when they already have so many issues to juggle during the course of managing a patient's medical problem list," he said. "On the other hand, we do feel that if nearly two out of three ophthalmologists themselves would avoid tamsulosin if they had BPH and cataract, it makes sense that those same ophthalmologists would want their patients to understand the situation and to hear about other options." For more information The entire educational update statement and the Journal of Cataract and Refractive Surgery article are accessible via the American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) Web sites. ACP http://www.acponline.org/clinical_information/journals_publications/acp_internist/weekly /2008/7/1/index.html#iris AAFP http://www.aafp.org/online/en/home/publications/news/news-now/clinical-care-research /20080702alpha-cataract.html POST A COMMENT Please complete the form below to post your comment. Bold = Required Your email address will NOT be published. Email Address appears with your comment Display Name City State Country Remember me: Yes Comment No read our privacy policy Note: does not support HTML All comments submitted are subject to review, and may be delayed before posting. We reserve the right not to post comments. 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